Pediatrics

A 9-year-old boy is brought to the emergency department by his parents due to rapidly worsening shortness of breath, a severe cough, and chest tightness over the past 24 hours. He has a history of moderate persistent asthma, and his home regimen includes daily inhaled fluticasone and as-needed albuterol. Over the last 12 hours, he has been using his albuterol inhaler every 2 hours without significant relief. His temperature is 37.1°C (98.8°F), heart rate is 148/min, respiratory rate is 42/min, and blood pressure is 115/72 mmHg. Oxygen saturation is 88% on room air. On physical examination, the patient is speaking only in single words, sitting leaning forward in a tripod position, and exhibiting marked intercostal and suprasternal retractions. Lung auscultation reveals globally poor air entry with very faint expiratory wheezing. Which of the following interventions are indicated in the initial emergency management bundle for this patient? (Select 3)

An 8-year-old boy is evaluated in the clinic for unusual behaviors. His parents report that for the past 15 months, he has had intermittent episodes of rapid eye blinking, facial grimacing, and shoulder shrugging. Additionally, for the last 6 months, he has been frequently grunting and sniffing loudly. These actions occur many times a day and worsen when he is stressed about schoolwork. He is fully conscious during the episodes and says he feels a "build-up of tension" that is relieved only by performing the actions. Physical and neurologic examinations are otherwise unremarkable. Which of the following is the most likely diagnosis?

A 14-hour-old male neonate, born at 39 weeks gestation, develops severe generalized cyanosis and tachypnea. Vital signs are temperature 36.8°C, heart rate 170/min, respiratory rate 75/min, and blood pressure 62/40 mm Hg. Pulse oximetry is 62% on room air. The patient is placed on 100% oxygen via a non-rebreather mask, and repeat pulse oximetry 15 minutes later is 64%. An intravenous infusion of alprostadil is immediately initiated. One hour later, the neonate remains profoundly cyanotic with an SpO₂ of 66% and exhibits severe intercostal retractions. Echocardiography demonstrates atrioventricular concordance with ventriculoarterial discordance. The ventricular septum is intact. A patent ductus arteriosus is present with bidirectional shunting. The interatrial septum bulges into the right atrium, and color Doppler reveals a 1.2-mm patent foramen ovale with a high-velocity, restrictive left-to-right shunt. Which of the following is the most appropriate next step in the management of this patient?

A 12-year-old boy is brought to the outpatient clinic by his parents due to a 4-week history of dull, aching pain in his left knee. The pain worsens after physical activity and improves with rest. He denies any direct trauma, falls, or fevers. His medical history is unremarkable, and his BMI is 32 kg/m². Vital signs are within normal limits. On physical examination, the patient has an antalgic gait and walks with the left foot pointing slightly outward. Inspection and palpation of the left knee reveal no erythema, swelling, or focal point tenderness. Anterior drawer, posterior drawer, and McMurray tests of the knee are negative. When the patient is placed in the supine position and the left hip is passively flexed to 90 degrees, the thigh obligately rotates externally. Which of the following is the most appropriate next step in diagnosis?

A pediatric resident is reviewing the standard age-appropriate diagnostic and management strategies for Developmental Dysplasia of the Hip (DDH). Arrange the following clinical steps in the correct chronological order, starting from the earliest appropriate age of implementation (newborn) to the latest (> 6 months of age).

During a routine follow-up visit at the pediatric clinic, a $5$-day-old boy is noted to be profoundly lethargic with increased work of breathing. The mother reports that he has been sweating profusely during attempts to breastfeed over the last $12$ hours and has not produced a wet diaper since yesterday. The pregnancy and term delivery were uncomplicated, and he was discharged home at $48$ hours of life without any apparent issues. Vital signs show a temperature of $36.5^\circ\text{C}$ ($97.7^\circ\text{F}$), heart rate of $190/\text{min}$, and respiratory rate of $72/\text{min}$. Blood pressure is $88/54 \text{ mm Hg}$ in the right upper extremity and $48/30 \text{ mm Hg}$ in the left lower extremity. Physical examination reveals a mottled, poorly responsive neonate with significant subcostal retractions and nasal flaring. Auscultation of the chest demonstrates a prominent parasternal heave, a harsh systolic murmur heard best over the left paravertebral interscapular area, and diffuse bilateral crackles. Palpation reveals bounding brachial pulses, but the femoral pulses are completely imperceptible. Pulse oximetry indicates an oxygen saturation of $97\%$ on the right hand and $84\%$ on the right foot. Arterial blood gas reveals a pH of $7.12$, $pCO_2$ of $32 \text{ mm Hg}$, and $HCO_3^-$ of $10 \text{ mEq/L}$. Which of the following is the most appropriate initial step in the management of this patient?

A 6-day-old girl is rushed to the emergency department due to a sudden onset of lethargy and rapid breathing. Her parents report that she had been feeding well until 12 hours ago but has progressively become difficult to arouse. She was born at 39 weeks gestation following an uncomplicated pregnancy and was discharged home on her second day of life.

Physical examination reveals an ashen, mottled infant with severe intercostal retractions. Capillary refill is 5 seconds. Brachial pulses are palpable, but femoral and pedal pulses are absent bilaterally. The liver edge is palpated 4 cm below the right costal margin. Arterial blood gas analysis demonstrates a pH of 7.15, $pCO_2$ of 32 mm Hg, and $pO_2$ of 65 mm Hg.

Which of the following is the most appropriate next step in the management of this patient?

A $7$-year-old female patient is seen in the pediatric endocrinology office for an evaluation of early physical maturation. The parents first noticed the development of breast tissue about $8$ months ago. Recently, she has outgrown her clothes much faster than her peers. On physical examination, her height is at the $95$ th percentile, whereas she had historically tracked along the $50$ th percentile. She has Tanner stage $3$ breasts and Tanner stage $2$ pubic hair. Radiographic assessment of the left wrist indicates a skeletal age of $10$ years. A random serum luteinizing hormone (LH) level is markedly elevated. Which of the following is the most appropriate next step in the evaluation of this patient?

A macrosomic male infant born at $39$ weeks gestation develops persistent hypoglycemia. At $24$ hours of life, despite receiving a continuous intravenous infusion of $10\%$ dextrose at a glucose infusion rate (GIR) of $8$ mg/kg/min, his point-of-care blood glucose is $40$ mg/dL. He is lethargic but maintaining his airway and hemodynamic stability. The medical team suspects congenital hyperinsulinism and prepares to definitively evaluate and manage his condition.

Arrange the following steps in the optimal sequential order for the diagnostic workup and management of this patient.

A 5-year-old boy is brought to the emergency department with an acute onset of right hip pain and a complete refusal to bear weight. His temperature is 39.2°C (102.6°F). Laboratory studies reveal a leukocyte count of 15,000/mm³ and an erythrocyte sedimentation rate (ESR) of 65 mm/h. Plain radiographs of the pelvis and bilateral lower extremities are unremarkable. Given the high probability of a severe bacterial joint infection based on these clinical and laboratory findings, the medical team proceeds with definitive evaluation and treatment.

Arrange the following interventions in the most appropriate chronological sequence for the management of this patient.

A 5-year-old girl is rushed to the emergency department by ambulance following a rapid decline in mental status. She has a known history of lumbar myelomeningocele and a ventriculoperitoneal shunt. According to the paramedics, the patient's parents reported that she suffered from unremitting headaches and projectile vomiting over the preceding 24 hours. On evaluation, she does not open her eyes or verbalize, and she exhibits decerebrate posturing to painful stimuli. Vital signs demonstrate a blood pressure of 148/92 mm Hg, a pulse of 48/min, and irregular respirations of 8/min. Neurologic examination highlights anisocoria, with the right pupil measuring 7 mm and unreactive to light, while the left pupil is 3 mm and briskly reactive. Determine the most appropriate chronological sequence for the management of this patient.

Match each patient's clinical vignette with the most appropriate initial targeted intervention.

A 15-month-old girl is brought to the clinic for a well-child visit. She was born prematurely at 28 weeks of gestation. The parents are concerned because she is not yet walking independently and her legs often seem 'stiff' when changing her diaper. On physical examination, there is increased muscle tone, hyperreflexia, and sustained clonus in both lower extremities. She stands on her toes when supported. The pediatrician suspects spastic diplegic cerebral palsy. Which of the following statements regarding this patient's clinical presentation and development are accurate? (Select all that apply.)

A 14-month-old boy is brought to the pediatric clinic for evaluation of a chronic, wet-sounding cough and poor weight gain. The family recently immigrated to the United States from a rural region with limited healthcare access. According to his parents, he has been hospitalized three times in the past year for what was described as "severe bronchiolitis" requiring supplemental oxygen. Between these acute episodes, he continues to have a daily cough. Despite eating vigorously, his weight has fallen from the 50th percentile at birth to the 3rd percentile currently. His mother also notes that his diapers are frequently difficult to clean due to unusually large, greasy, and foul-smelling stools. On physical examination, the child appears pale with a protuberant abdomen. Vital signs show a temperature of 37.1°C (98.8°F), pulse of 120/min, and respiratory rate of 34/min. Lung auscultation reveals diffuse coarse crackles and scattered expiratory wheezes bilaterally. Which of the following is the most appropriate next step in the management of this patient?

A 7-year-old girl is brought to the emergency department presenting with severe respiratory distress, marked suprasternal retractions, and diffuse expiratory wheezing, consistent with status asthmaticus. Over the course of her evaluation, she demonstrates a progressive, step-wise deterioration. She fails to adequately respond to each successive tier of medical therapy, eventually developing a rising $PaCO_2$ and lethargy that necessitates definitive airway control. Arrange the following acute interventions in the standard chronological order of escalation for a pediatric patient with refractory status asthmaticus.

Pair the following pediatric clinical presentations and laboratory findings with their corresponding endocrine diagnoses.

Match the following classic pediatric clinical presentations and physical examination findings with their most likely underlying congenital heart disorder.

A $3$-year-old girl is brought to the emergency department by her parents due to a sudden refusal to walk since waking up this morning. She has been unusually fussy and had a fever for the past $24$ hours. Her temperature is $39.0^\circ C$ ($102.2^\circ F$). On physical examination, she is lying still on the examination table and keeps her right hip flexed, abducted, and externally rotated. Any passive movement of the right hip elicits severe crying and guarding. There is no history of recent trauma. Arrange the following steps in the most appropriate chronological sequence for the standard diagnostic workup and management of this patient's condition.

Match the following classic clinical presentations with the most likely underlying pediatric genetic or metabolic disorder.

Review the following pediatric case scenarios involving abnormal physical findings or thyroid function laboratory results. Pair each patient profile with the correct underlying endocrine etiology.